Open access
Epidemiology of placenta previa accreta:
To cite: Jauniaux E, Grønbeck L,
Bunce C, et al. Epidemiology
of placenta previa accreta:
a systematic review and
meta-­analysis. BMJ Open
2019;9:e031193. doi:10.1136/
bmjopen-2019-031193
►► Prepublication history and
additional material for this paper
are available online. To view
please visit the journal (http://​
dx.​doi.​org/​10.​1136/​bmjopen-​
2019-​031193).
Received 21 April 2019
Revised 04 October 2019
Accepted 16 October 2019
© Author(s) (or their
employer(s)) 2019. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
1 invasive grades of placenta increta, where
EGA Institute for Women Health,
UCL, London, UK
2
Department of Obstetrics,
Rigshospitalet, University of
Copenhagen, Kobenhavns,
Denmark
3
Primary Care and Public
Health Sciences, King's College
London, London, UK
4
Departement of Obstetrics,
Rigshospitalet, University of
Copenhagen, Kobenhavn,
Denmark
5
Nuffield Department of
Women’s and Reproductive
Health, University of Oxford,
Oxford, UK
Correspondence to
Professor Eric Jauniaux;
​e.​jauniaux@​ucl.​ac.​uk
a systematic review and meta-­analysis
Eric Jauniaux ‍ ‍ ,1 Lene Grønbeck,2 Catey Bunce ‍
Sally L Collins5
Abstract
Objective  To estimate the prevalence and incidence of
placenta previa complicated by placenta accreta spectrum
(PAS) and to examine the different criteria being used for
the diagnosis.
Design  Systematic review and meta-­analysis.
Data sources  PubMed, Google Scholar, ​ClinicalTrials.​gov
and MEDLINE were searched between August 1982 and
September 2018.
Eligibility criteria  Studies reporting on placenta previa
complicated by PAS diagnosed in a defined obstetric
population.
Data extraction and synthesis  Two independent
reviewers performed the data extraction using a
predefined protocol and assessed the risk of bias using
the Newcastle-­Ottawa scale for observational studies, with
difference agreed by consensus. The primary outcomes
were overall prevalence of placenta previa, incidence
of PAS according to the type of placenta previa and the
reported clinical outcomes, including the number of
peripartum hysterectomies and direct maternal mortality.
The secondary outcomes included the criteria used for the
prenatal ultrasound diagnosis of placenta previa and the
criteria used to diagnose and grade PAS at birth.
Results  A total of 258 articles were reviewed and 13
retrospective and 7 prospective studies were included in
the analysis, which reported on 587 women with placenta
previa and PAS. The meta-­analysis indicated a significant
(p<0.001) heterogeneity between study estimates for
the prevalence of placenta previa, the prevalence of
placenta previa with PAS and the incidence of PAS in
the placenta previa cohort. The median prevalence of
placenta previa was 0.56% (IQR 0.39–1.24) whereas the
median prevalence of placenta previa with PAS was 0.07%
(IQR 0.05–0.16). The incidence of PAS in women with a
placenta previa was 11.10% (IQR 7.65–17.35).
Conclusions  The high heterogeneity in qualitative and
diagnostic data between studies emphasises the need
to implement standardised protocols for the diagnoses
of both placenta previa and PAS, including the type of
placenta previa and grade of villous invasiveness.
PROSPERO registration number  CRD42017068589
Introduction
Placenta accreta is a pathological condition
of placentation associated with a high risk
of massive obstetric haemorrhage during
delivery. Initially described in 1937 by Irving
and Hertig1 as the abnormal adherence
Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193
Original research
‍ ,3 Jens Langhoff-­Roos,4
Strengths and limitations of this study
►► This study provides the first comprehensive evalua-
tion of the epidemiology of placenta previa compli-
cated by placenta accreta spectrum (PAS).
►► The search was performed using predetermined
eligibility criteria in a defined obstetric population.
►► Thirteen out of 20 studies included in the study
were retrospective limiting the overall quality of the
analysis.
►► Only six studies provided data on the prenatal ul-
trasound diagnosis of PAS in patients with placenta
previa and nine studies on detailed histopathological
findings.
►► High level of inconsistency between estimates in
prevalence and incidence did not allow for full meta-­
analysis of the clinical outcomes.
of the placenta to the myometrium due to
the partial or complete absence of decidua
basalis, it was subsequently redefined by Luke
et al2 as a spectrum of abnormally adherent
and invasive placentation disorders. Placenta
accreta is now graded according to the depth
of the villous penetration into the uterine
wall starting with the abnormally adherent
placenta or creta, where the villi attach
directly to the surface of the myometrium
without invading it, and extending to the
the villi penetrate deeply into the myome-
trium up to the uterine serosa, and placenta
percreta, where the invasive villous tissue
penetrates through the uterine serosa often
entering the surrounding pelvic tissues.3–5
The different grades of the placenta accreta
spectrum (PAS) can coexist in the same spec-
imen and can be focal (just a small area of the
placental bed) or extensive (including much
of the placental bed).2
Over the last two decades, a growing body of
epidemiology research has identified the effect
of the rapid increase in caesarean delivery rates
on the risks of PAS.6–10 The main additional
risk factor after a previous caesarean delivery
is placenta previa. A large multicentric US
cohort study noted that for women presenting
1
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with placenta previa and prior caesarean delivery, the risk
of PAS was 3%, 11%, 40%, 61% and 67% for first, second,
third, fourth and fifth or more caesarean deliveries,
respectively.7 A national case–control study using the UK
Obstetric Surveillance System found that the incidence
of PAS increases from 1.7 per 10 000 births overall to 577
per 10 000 births in women with both a previous caesarean
delivery and placenta previa.8
Both abnormal adherence and invasion of villous tissue
into the myometrium result in failure of the placenta to
separate spontaneously from the uterine wall at delivery.2–4
When unsuspected at the time of delivery, attempts to
manually remove accreta villous tissue typically provoke
rapid bleeding from the uteroplacental circulation.5 11 In
invasive cases, this can lead to massive obstetric haemor-
rhage due to the disruption of the deep uterine vascula-
ture of the increta or percreta area.4 5 Not surprisingly,
prenatal diagnosis of PAS has been shown to decrease
maternal morbidity and mortality, and has thus become
essential in improving its management.12 13 Tabsh et al
were the first in 1982 to report on the prenatal ultrasound
diagnosis of a case of placenta increta.14 A recent system-
atic review and meta-­analysis of prenatal ultrasound diag-
nosis of placenta previa with PAS in women with a history
of caesarean delivery has found that the overall diagnostic
accuracy of ultrasound in specialist units is in 90.9%.15
However, in countries with well-­ established screening
programmes for fetal anomalies, over half the cases of
PAS are not diagnosed before delivery.8 10
Accreta placentation and in particular its invasive forms
are impacting maternal health outcomes globally and its
prevalence is likely to increase. Women with a history of
previous caesarean delivery presenting with placenta previa
complicated by PAS in an ongoing pregnancy are now the
cohort of obstetric patients with the highest risk of delivery
complications,16 however, their epidemiology has not been
comprehensively reviewed yet. Health provision for the
development of maternity centres with specialist teams,
equipment, drugs, blood bank and intensive care infra-
structure to safely manage women presenting with placenta
previa and PAS requires an accurate evaluation of its epide-
miology. The objective of this meta-­analysis is to review the
epidemiology of women presenting with placenta previa
and to examine the different criteria used by the authors of
cohort studies to diagnose placenta previa and PAS prena-
tally and to confirm the diagnosis of PAS at birth.
Materials and methods
A systematic review was undertaken of articles providing data
on prevalence and incidence of PAS in women presenting
with a placenta previa where the populations sampled were
defined. PubMed, Google Scholar, C ​ linicalTrials.​gov and
MEDLINE were searched for studies published between
the first prenatal ultrasound description of placenta accreta
in August 1982 by Tabsh et al14 and September 2018. The
overall search strategy was inclusive of MeSH headings for
the following terms ‘placenta accreta, placenta increta,
2 Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193
placenta percreta, abnormally invasive placenta, morbidly
adherent placenta and major placenta previa’ (search
strategy in online supplementary data 1). Title, abstracts
and full text were independently assessed by the authors for
content, data extraction and analysis. Additional relevant
studies were identified from reference lists of reviews and
editorials and by handsearching key journals and websites.
All search results were combined in a reference database.
Duplicates were removed by hand. The search was limited
to articles published in English.
Two independent investigators (EJ and LG) selected
studies in two stages. The abstracts of all potentially rele-
vant papers were individually examined for suitability.
Papers were only ruled out at this stage if they obviously
did not meet the inclusion criteria. The remainders were
obtained in full text and were independently assessed
for content, data extraction and analysis. Disagreements
between the two original reviewers were resolved by
discussion with the third investigator (JL-­R). Articles were
excluded if; they were published before August 1982,
contained no data on the study population such as the
overall pregnancies, births and/or deliveries numbers,
were case reports or were overlapping.
Study characteristics were extracted using a prede-
signed data extraction protocol including: author institu-
tion, year of publication, country of origin, study period,
study type (retrospective, single institution, multiple insti-
tutions), total number of cases in the study population,
type of placenta previa, diagnosis of PAS at birth (search
strategy in online supplementary data 2). Outcome
measures included the need to perform a peripartum
hysterectomy and direct maternal mortality. Prior surgical
history was also recorded. The reference standard for
differential diagnosis between minor and major placenta
previa was recorded based on the placental position inside
the uterine cavity on transvaginal ultrasound with relation
to the internal cervical os. For the diagnosis of accreta
placentation, we referred to the clinical grading based on
surgical findings at delivery as previously described17 and
to histopathological findings when a caesarean hyster-
ectomy was performed, that is, placental villi directly
attached to the myometrium without interposing decidua
or invading the uterine wall.
Two independent reviewers (EJ and LG) undertook the
quality assessment with difference agreed by consensus.
The Newcastle-­ Ottawa scale for observational studies
was used to establish the risk of bias in selection (repre-
sentativeness of the exposed cohort, ascertainment of
exposure and the demonstration that the outcome of
interest was not present at the start of the study), compa-
rability (evaluation of the cohorts based on the design
or analysis) and outcome assessment.18 These included
retrospective versus prospective studies, single versus
multiple institutions studies, prenatal ultrasound descrip-
tion of low-­lying/placenta previa and PAS, histopatho-
logical confirmation of the diagnosis of the PAS and
corresponding grade of invasiveness and detailed data
on management and maternal outcomes. Studies that

scored four stars for selection, two stars for comparability
and three stars for ascertainment of the outcome were
regarded to have a low risk of bias. Studies with two or
three stars for selection, one for comparability and two
for outcome ascertainment were considered to have a
medium risk of bias. We deemed any study with a score of
one for selection or outcome ascertainment, or zero for
any of the three domains, to have a high risk of bias. No
study was excluded based on the risk of bias assessment.
Analyses were conducted using STATA software (V.15;
StataCorp). Standard Kurtosis analysis indicated that some
values were not normally distributed and study specific
estimates are therefore presented as median and IQR. A
random-­ effects model was used to combine the studies
while incorporating variations among studies unless there
were three or less studies contributing to the meta-­analysis
in which case a fixed-­ effect model was used. Statistical
heterogeneity was assessed with the Cochran’s Q-­test and
the I2 statistic (the proportion of variation in study estimates
because of heterogeneity rather than sampling error).
Forest plots are presented to graphically summarise the
study results and the pooled results. A test for heterogeneity
between subgroups (ie, study types) was conducted.
Patients and public involvement
Patients and the public were not involved in the design or
planning of the study.
Results
The initial search provided 256 records with cross-­
referencing providing an additional two studies, making a
total of 258 potentially relevant articles. After exclusion of
duplicates and the two which were not available (figure 1),
220 remained. On screening the titles and abstracts, a
further 162 were excluded as the reported outcomes were
Figure 1  Flow diagram showing the selection of reports
included in the review.
Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193
Open access
not relevant, leaving 58 studies which were obtained for full
text review. An additional 38 articles were excluded after full
review including letters (n=16), narrative reviews (n=10)
commentaries (n=9), conference proceedings (n=2) and
duplication of data in another publication (n=1), leaving
20 articles for the final analysis.19–38
There were 13 retrospective19 20 23 25–27 29–31 33–35 38 and
7 prospective21 22 24 28 32 36 37 studies including a total
of 1 207 296 births and 23 864 cases referred as preg-
nancies. There were 15 studies from a single institu-
tion19–24 27–30 32–34 37 38 and 5 from multiple institutions25 31
or a geographical region.26 35 36 Overall, 18 studies had
low or medium risk of bias (full data in online supple-
mentary data 3).
Table 1 presents the epidemiology data of the 20
studies. These studies included 587 women with placenta
previa complicated by PAS out of 6628 cases of placenta
previa. The median prevalence of placenta previa in the
20 studies was 0.56% (IQR 0.39–1.24) whereas the median
prevalence of placenta previa with PAS was 0.07% (IQR
0.05–0.16). The median incidence of PAS in women with
a placenta previa was 11.10% (IQR 7.65–17.35).
All authors except two29 33 reported on the criteria used
for the prenatal ultrasound diagnosis of placenta previa.
Six studies24 26 30 32 37 38 only included major placenta previa
in their cohort as defined as the placenta completely
covering or partially covering the internal os of the cervix.
The others included both major and minor placenta
previa. The definition of minor placenta previa varied
with two studies31 36 using the placental edge being <2 cm
from the internal os, two studies using <3 cm22 2323 and one
study using <3 cm or <5 cm if associated with abnormal
fetal presentation.21 The gestational age at confirmation
of the prenatal diagnosis of placenta previa was reported
in six studies22–24 28 32 37 and ranged between 20 and 34
weeks and in one study the diagnosis of placenta previa
was confirmed at birth when the placenta was found to be
inserted in the lower segment.19
The ultrasound diagnostic signs for PAS were reported in
six studies24 28 30 32 36 37 with two studies also reporting on the
use of MRI.29 38 The clinical criteria used for the diagnosis of
PAS at birth were reported by nine studies19 20 23 27 28 30 33 36 37
and included a difficult delivery of the placenta without easy
separation uterine wall or requiring a ‘piecemeal removal’
associated with heavy bleeding and excessive bleeding
from the placental bed after placental delivery. One author
described the presence of invasive villous tissue at delivery27
and one the need to suture the placental bed.23 None of
the other authors reported on the gross appearance of the
uterus or surgical findings at the time of caesarean delivery.
In 12 studies,19 23 24 27–31 33 34 36 37 the prenatal and/or clinical
diagnosis was confirmed by histopathological examination
with detailed description of the microscopic criterion only
reported in six.19 27 28 30 31 37 Detailed histopathological find-
ings on the depth of villous invasiveness were reported in
9 studies24 27–29 31 33 34 36 37 out of the 20 studies (table 2).
These included 283 cases of placenta previa accreta graded
for 171 (60.4%) as placenta accreta (adherent), 74 (26.2%)
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Table 1  Prevalence of placenta previa with placenta accreta spectrum (PAS) per pregnancies or births in the corresponding
obstetric population and incidence of PAS per cohorts of placenta previa
References Obstetric population Prevalence (%) Incidence (%)
19
Chattopadhyay et al 41 206 births 26 (0.063) 26/222 (11.7)
Zaki et al20 23 070 births 12 (0.052) 12/110 (10.9)
Ziadeh et al21 18 651 births 13 (0.070) 13/65 (20.0)
22
Ghourab 18 670 births 11 (0.059) 11/138 (8.0)
Bahar et al23 42 487 births 53 (0.125) 53/306 (17.3)
24
Hamada et al 2413 births 5 (0.207) 5/70 (7.1)
25
Jang et al 35 030 births 53 (0.151) 53/560 (9.5)
Rosenberg et al26 185 476 births 23 (0.012) 23/779 (3.0)
27
Kassem and Alzahrani 29 053 births 25 (0.085) 25/122 (20.5)
Maher et al28 24 661 births 42 (0.170) 42/577 (7.3)
29
Alchalabi et al 16 845 births 23 (0.137) 23/81 (28.4)
30
Asicioglu et al 112 819 births 46 (0.041) 46/364 (12.6)
Sumigama et al31 96 670 births 46 (0.048) 46/954 (4.8)
32
Ahmed et al 3841 births 14 (0.365) 14/52 26.9
Cheng and Lee33 81 497 births 39 (0.048) 39/921 (4.2)
34
Cho et al 11 210 pregnancies 39 (0.348) 39/442 (8.8)
35
Kollmann et al 218 876 births 13 (0.006) 13/328 (4.0)
Pilloni et al36 108 000 births 37 (0.034) 37/314 (11.8)
37
Rezk and Shawky 12 654 pregnancies 53 (0.419) 53/74 (71.6)
Wortman et al38 148 031 births 14 (0.010) 14/157 (8.9)

as placenta increta and 38 (13.4%) as placenta percreta.
These studies included a total of 383 003 pregnancies
or births and the prevalence for the different grades of
placenta previa accreta was 0.05%, 0.02% and 0.01% for
creta, increta and percreta, respectively.
The meta-­ analysis indicated statistically significant
(p<0.001) level of overall heterogeneity between study
estimates for the prevalence of placenta previa (figure 2),
the prevalence of placenta previa with PAS (figure 3)
and the incidence of PAS in the placenta previa cohort
(figure 4). There was strong evidence of inconsistency
between study types with I2 values greater 85%. The differ-
ence in heterogeneity between prospective versus retro-
spective studies was not statistically significantly (p=0.839)
different (figure 2) whereas it was significant (p=0.014)
for the prevalence of placenta previa accreta (figure 3).
Adjusting for type of study (prospective vs retrospec-
tive) did not reduce inconsistency between studies. The
in-­between placenta previa major only versus minor and
major placental previa was not significant (p=0.067) for

Table 2  Studies presenting detailed histopathological data on the depth of villous invasiveness (PAS grades)

No of cases analysed/no of PAS grades

References cases included in the study PC (%) PI (%) PP (%)
24
Hamada et al 5/5 3 (60.0) 2 (40.0) --
Kassem and Alzahrani27 19/25 13 (68.4) 5 (26.3) 1 (5.3)
28
Maher et al 42/42 28 (66.6) 13 (31.0) 1 (2.4)
Achalabi et al29 23/23 15 (65.2) 4 (17.4) 4 (17.4)
31
Sumigama et al 46/46 14 (30.4) 21 (45.7) 11 (23.9)
33
Cheng and Lee 39/39 36 (92.3) -- 3 (7.7)
Cho et al34 39/39 24 (37.4) 11 (31.3) 4 (31.3)
36
Pilloni et al 17/37 7 (41.2) 4 (23.5) 6 (35.3)
Rezk and Shawky37 53/53 31 (58.5) 14 (26.4) 8 (15.1)
Total 283/309 171 (60.4) 74 (26.2) 38 (13.4)

PAS, placenta accreta spectrum

4 Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193

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Figure 2  Forest plots showing the heterogeneity of prevalence data in prospective and retrospective cohort studies of women
presenting with a placenta previa. Only first author’s name is given for each reference. ES, effect size.

the incidence of PAS in patient with placenta previa
(figure 4).
All authors but two22 23 reported on prior surgical
history including caesarean section,19–21 24–38 uterine
curettage28 30–32 34 37 38 and myomectomy.28 36 37 Data on
surgical management were available in 14 out of the
20 studies19 20 23 27–31 33–38 with 314 out of 441 women
presenting with a placenta previa complicated by PAS.
The median peripartum hysterectomy rate of 69.2% (IQR
50.0–84.0). Data on maternal mortality were available in
13 studies19–21 23 25 27–30 32 35 37 38 and PAS accounted for
5 maternal deaths19 20 25 29 30 out of 387 (1.3%) cases of
placenta previa with PAS.
Discussion
This study provides a comprehensive evaluation of
the prevalence of placenta previa complicated by PAS
and the incidence of PAS in women presenting with a
placenta previa. Women with a prior history of caesarean
delivery presenting with a low-­ lying/placenta previa
represent more than 90% of the cases of PAS.8 10 16 The

Figure 3  Forest plots showing heterogeneity in the prevalence data for prospective and retrospective cohort studies of women
diagnosed with placenta previa accreta. Only first author’s name is given for each reference. ES, effect size.

Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193 5

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Figure 4  Forest plots showing the heterogeneity in cohort studies reporting incidence data for women diagnosed with
placenta previa major and PAS and those with either placenta previa minor or major and PAS. ES, effect size.; PAS, placenta
accreta spectrum.
meta-­analysis indicates high heterogeneity for both the
prenatal diagnosis of placenta previa and for the confir-
mation of the diagnosis of PAS at delivery. These find-
ings highlight the need to use international standardised
clinical protocols for the screening and management of
this complex obstetric condition. The current situation
limits the capacity building of healthcare providers on
improvements in training, implementation of guidelines
and changes in clinical practice behaviour.
Defining the position of the placenta inside the uterus
was one of the first aims of obstetric ultrasound exam-
ination.39 40 Following the development of real-­time ultra-
sound imaging, placental location became an integral
part of the mid-­ pregnancy ultrasound examination.41
Placenta previa was initially described with transabdom-
inal scan as a placenta developing within the lower uterine
segment and classified according to the relationship and/
or the distance between the lower placental edge and the
internal os of the uterine cervix, that is, minor placenta
previa when lower edge is inside the lower uterine segment
down to the internal os and major placenta previa when
the placenta covers the cervix. Minor placenta previa can
be further subdivided into low-­lying placenta when the
lower edge does not reach the internal os and marginal
placenta previa when it does. Major placenta previa can
also be described as partial or complete depending on the
amount of placental tissue covering the cervix. The use
of transvaginal scanning has allowed for a more precise
evaluation of the distance between the placental edge
and the internal os42 43 but as demonstrated in our meta-­
analysis, the reporting of the ultrasound criteria used for
the diagnosis of placenta previa has been heterogeneous.
6 Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193
In addition, we found also wide variation in the gesta-
tional age at diagnosis. The timing of the confirmation
of the diagnosis has a direct impact on epidemiology data
as up to 70% of minor placenta previa at 20–23 weeks
of gestation will resolve by 32–35 weeks.44 45 An expert
panel of the American Institute of Ultrasound in Medi-
cine46 has recently recommended ceasing the use of
the terms ‘partial’ and ‘marginal’ and using the term
‘placenta previa’ only when the placenta lies directly
over the internal os. The placenta should be reported as
‘low-­lying’ when the placental edge is less than 2 cm from
the internal os and as normal when the placental edge
is more than 2 cm from the internal os. The findings of
our meta-­analysis highlight the need for the use of such a
classification in further studies.
Only 6 of the 20 studies included in the present meta-­
analysis provided data on the prenatal ultrasound diag-
nosis of PAS in patients with placenta previa. We included
in the systematic review all studies published since the
first ultrasound description of PAS by Tabsh et al.14 We
found no studies between 1982 and 1993 (table 1), which
corresponds to the time when high-­resolution grey-­scale
ultrasound imaging became widely available. Colour
Doppler imaging was introduced for the diagnosis of PAS
in 1992,47 however, the sensitivity and specificity of grey-­
scale imaging alone in diagnosing for placenta previa
accreta are high when performed by the experience oper-
ators.15 These findings indicate that the prenatal diag-
nosis of PAS can be performed using standard ultrasound
equipment. Unlike placenta previa which is routinely
screened for at the time of the fetal anomaly scan, PAS
is currently not screened for and the data available on

the prenatal diagnosis of the condition come exclusively
from specialist centres.16 In these centres, the diagnostic
accuracy of ultrasound imaging is over 90%, but similar
to placenta previa, the description of the ultrasound signs
used for the diagnosis of PAS has also been highly vari-
able over the last two decades.47 48 The European Working
Group on Abnormally Invasive Placenta and the Abnor-
mally Invasive Placenta international expert group have
recently proposed standardised descriptions of the ultra-
sound signs used for the prenatal diagnosis and a protocol
for the ultrasound assessment of PAS.49 50 The use of these
protocols in prospective studies should also facilitate the
screening of patients at high risk of PAS and in particular
those with multiple prior caesarean deliveries presenting
with a low-­lying or placenta previa.51
We found significant heterogeneity in the qualitative
definition and diagnosis of PAS at birth among the nine
studies that provided a description of the clinical find-
ings.19 20 23 27 28 30 33 36 37 Only one of these studies described
the invasive appearance of placental tissue at delivery27
whereas the others reported a difficult delivery of the
placenta without easy separation from the uterine wall
or requiring a ‘piecemeal removal’ associated with heavy
bleeding as diagnostic of PAS. These clinical criteria
were first described by Irving and Hertig1 in 1937 who
did not have invasive cases in their cohort limiting their
definition to abnormally adherent placenta and not to
placenta increta or percreta. This definition also fails to
clearly differentiate between abnormal adherence and
placental retention as both present with similar clinical
symptoms and aetiology52 leading to possible over diag-
nosis of placenta previa accreta. Similarly, the finding of
excessive bleeding from the placental bed after delivery
of the placenta is a common complication of non-­
accreta placenta previa due to the implantation of the
placenta in the lower uterine segment which contains
less muscular fibres than the upper segment and is
often thinner and dehiscent after multiple caesarean
deliveries.
Detailed histopathological reports can only be obtained
in those patients who have a hysterectomy or a partial
myometrial resection and thus in many studies there is
not histopathological confirmation of the clinical diag-
nosis. The main histological diagnostic criteria of accreta
placentation, that is, absence of decidua between the
tip of anchoring villi and the superficial myometrium, is
found with increasing incidence with advancing gestation
in pregnancies with no clinical evidence of PAS.5 Thus,
the combination of clinical criteria that do not differen-
tiate between placenta retention and adherent accreta
and the use of non-­diagnostic criteria of villous invasive-
ness may result in the overdiagnosis of the adherent grade
of PAS (table 2), in particular in those studies reporting
a low rate of caesarean hysterectomy.28 36 Overall, this
can explain the wide range in the prevalence (0.04%–
0.42%) of placenta previa with PAS and incidence (2.9%–
71.6%) of PAS in women presenting with placenta previa
(figures 3 and 4).
Jauniaux E, et al. BMJ Open 2019;9:e031193. doi:10.1136/bmjopen-2019-031193
Open access
Overall, management strategies and outcomes will vary
depending on the accuracy of prenatal diagnosis, local
surgical expertise and more recently access to a centre of
excellence with multidisciplinary team approach.53 54 In
cases of high suspicion of PAS during caesarean delivery,
60%–70% of obstetricians-­gynaecologists proceed with a
peripartum hysterectomy.55 56 By contrast with a conser-
vative management approach, radical surgery is often
considered to be safer, in particular in cases of invasive
placentation.57 The association between a placenta previa
and a PAS increases the risks of both maternal morbidity
and mortality. In the present study, we found that a
caesarean hysterectomy was the primary management
option in around 70% of the patients presenting with a
placenta previa and PAS. The interstudy range was wide
with four studies19 21 29 37 reporting peripartum hysterec-
tomy rates <50%, five28 31 32 34 36 had rates between 50%
and 99% and four22 30 35 38 had rates of 100%. This may be
due to difference in study protocols, local expertise and
the impact of prenatal diagnosis on management strate-
gies but also as suggested by our analysis to difference in
the rates of the different grades of PAS and the accuracy
of clinical diagnosis at birth and detailed histopatholog-
ical examination confirming the diagnosis.
The main limitations of this review are the quality of
the published data. Thirteen out of 20 studies included in
the analysis studies were retrospective and there was wide
variation in the use of different ultrasound criteria for
the prenatal diagnosis of placenta previa, in the clinical
diagnosis of PAS at delivery and in the authors providing
detailed histopathology data to confirm the clinical diag-
nosis. This is hampering the meta-­analysis of the clinical
outcomes in particular the incidence of major haemor-
rhage at delivery and the need and amount of blood trans-
fusion but also the choice in management protocols and
in particular the use of conservative management proce-
dures. We would not, therefore, recommend the use of
the pooled estimates beyond that of a support towards the
development of standardised diagnostic protocols.
The prevalence of PAS in the general population of
women giving birth varies widely.8 10 58 59 A systematic
review and meta-­analysis of the prevalence of placenta
praevia has found evidence suggestive of regional varia-
tion.60 As both conditions are often associated with prior
caesarean sections, it is likely that national and local
caesarean delivery rates, expertise in diagnosing both
conditions antenatally and access to perinatal pathol-
ogist to confirm the diagnosis of PAS at birth will influ-
ence these epidemiology data. There is a need for further
prospective multicentre studies with participatory meth-
odologies involving local service providers and facility
management to accurately evaluate the consequences of
high caesarean sections rates on maternal health within
a particular population. Within this context, accurate
epidemiological data on PAS disorders are essential in
planning screening programmes and in making provi-
sion for the development of centres of excellence for
the management of this increasingly common complex
7
 Open access
obstetric condition. While the concept of core outcome
measures within clinical trials is now well recognised and
championed, greater efforts are required to disseminate
this approach in epidemiological research to facilitate
global estimation and recognition of problems emerging
on a worldwide scale. Our study supports implementa-
tion, in both clinical practice and in reporting data on
placenta previa accreta in the medical literature, of stan-
dardised protocols for prenatal diagnosis of both placenta
previa and PAS, for the clinical diagnosis of PAS at birth
and for the histopathological confirmation examination.
Contributors  EJ, CB and JL-­R contributed equally to the study design. EJ, LG
and JL-­R collected the data and carried out the qualitative analysis. CB and EJ
carried out the quantitative analysis. EJ, JL-­R and SLC drafted the manuscript. All
authors were involved in the critical discussion and approved this final version for
publication. EJ is the guarantor of the study.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  Data are available on reasonable request.
Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
ORCID iDs
Eric Jauniaux http://​orcid.​org/​0000-​0003-​0925-​7737
Catey Bunce http://​orcid.​org/​0000-​0002-​0935-​3713
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